Acute Care Visit Note (Family Medicine)

Patient: [name, DOB]

Date of Service: [date]

Provider: [name, credentials]

Chief Complaint: [patient's primary concern in their words]

Subjective

[Focused HPI for primary problem] (Use 1–3 short paragraphs. Cover onset/duration/course, key symptom characteristics, pertinent positives and negatives, prior episodes or self-treatment, and relevant exposures/risk factors. Integrate relevant history/medications/allergies only when they affect today's management.)

[Additional problem]: [Focused HPI for additional problem] (Include separate brief paragraph for each additional acute complaint; omit if single-problem visit.)

[Additional ROS outside HPI] (Single sentence naming other systems reviewed only if clinically relevant; omit if not performed.)

Objective

Vitals: [relevant vital signs with values]

Exam: [pertinent findings organized by system] (Include only systems examined with meaningful positives and negatives.)

Data: [point-of-care tests, labs, or imaging reviewed today with results and brief interpretation; note tests ordered and pending] (Omit this line entirely if no data were obtained or reviewed.)

Assessment & Plan

(Organize by problem in order of clinical urgency. For single-problem visits, use one concise paragraph that still includes explicit return precautions.)

[Problem 1]: [working diagnosis or symptom-based assessment]

[Brief clinical reasoning linking key findings to assessment] (Include differential considerations if diagnosis is uncertain or serious alternatives were evaluated.)

• Diagnostics: [studies ordered today] (Omit if none ordered.)
• Treatment: [medications with dose/route/frequency/duration; non-pharmacologic care] (If antibiotics prescribed or withheld, briefly document rationale.)
• Education: [patient education and shared decision-making points] (Omit if not applicable.)
• Follow-up: [timing and venue]
• Return precautions: [specific warning signs and where to seek care: call clinic / urgent care / ED]

(Repeat problem structure above for each additional problem addressed. Omit if single-problem visit.)

Procedure

(Include this section only if a procedure was performed; otherwise omit entirely.)

Indication: [reason for procedure]

Consent: [consent obtained; risks/benefits/alternatives discussed]

Technique: [brief summary including anesthesia and materials used]

Findings: [key intra-procedural findings and immediate outcome]

Post-procedure instructions: [wound care, activity limits, medications, follow-up]